[Show abstract][Hide abstract] ABSTRACT: Background: Some cases of subarachnoid haemorrhage (SAH) have been associated with vigorous physical activity, including sports. Our research aimed to describe the association between SAH and sports and to identify the types of sports that were more frequently found as precipitating factors in a tertiary single-centre SAH register. Methods: We retrieved information from a prospectively collected SAH registry and reviewed discharge notes of acute SAH patients admitted to the Stroke Unit of Hospital de Santa Maria, Lisbon, between 1995 and 2014. Results: Out of 738 patients included in the analysis, 424 (57.5%) cases of SAH were preceded by physical activity. Nine cases (1.2%) were associated with sports, namely running (2 cases), aerobics (2 cases), cycling, body balance, dance, surf and windsurf. Patients with SAH while practicing sports were younger than controls (average age 43.1 vs. 57.0 years; p = 0.007). In 1 patient, there was a report of trauma to the neck. Patients in the sports group only had Hunt and Hess scale grades 1 (11.1%) or 2 (88.9%) at admission, while patients in the control group had a wider distribution in severity. Conclusions: Our findings indicate that SAH precipitated by sports is not very frequent and is uncommonly related to trauma. Patients who suffered SAH associated with sports were younger and apparently had a milder clinical presentation.
[Show abstract][Hide abstract] ABSTRACT: IMPORTANCE Type 2 diabetes mellitus and associated chronic kidney disease (CKD) have become major public health problems. Little is known about the influence of diet on the incidence or progression of CKD among individuals with type 2 diabetes. OBJECTIVE To examine the association between (healthy) diet, alcohol, protein, and sodium intake, and incidence or progression of CKD among individuals with type 2 diabetes. DESIGN, SETTING, AND PARTICIPANTS All 6213 individuals with type 2 diabetes without macroalbuminuria from the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET) were included in this observational study. Recruitment spanned from January 2002 to July 2003, with prospective follow-up through January 2008. MAIN OUTCOMES AND MEASURES Chronic kidney disease was defined as new microalbuminuria or macroalbuminuria or glomerular filtration rate decline of more than 5% per year at 5.5 years of follow-up. We assessed diet using the modified Alternate Healthy Eating Index (mAHEI). The analyses were adjusted for known risk factors, and competing risk of death was considered. RESULTS After 5.5 years of follow-up, 31.7% of participants had developed CKD and 8.3% had died. Compared with participants in the least healthy tertile of mAHEI score, participants in the healthiest tertile had a lower risk of CKD (adjusted odds ratio [OR], 0.74; 95% CI, 0.64-0.84) and lower risk of mortality (OR, 0.61; 95% CI, 0.48-0.78). Participants consuming more than 3 servings of fruits per week had a lower risk of CKD compared with participants consuming these food items less frequently. Participants in the lowest tertile of total and animal protein intake had an increased risk of CKD compared with participants in the highest tertile (total protein OR, 1.16; 95% CI, 1.05-1.30). Sodium intake was not associated with CKD. Moderate alcohol intake reduced the risk of CKD (OR, 0.75; 95% CI, 0.65-0.87) and mortality (OR, 0.69; 95% CI, 0.53-0.89). CONCLUSIONS AND RELEVANCE A healthy diet and moderate intake of alcohol may decrease the incidence or progression of CKD among individuals with type 2 diabetes. Sodium intake, within a wide range, and normal protein intake are not associated with CKD. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00153101.
Full-text · Article · Aug 2013 · JAMA Internal Medicine
[Show abstract][Hide abstract] ABSTRACT: Background and purpose:
Lumbar puncture (LP) may precipitate cerebral venous thrombosis (CVT), but it is unclear if LP is deleterious in patients with CVT. We aimed to assess the safety of LP in the International Study on Cerebral Veins and Dural Sinus Thrombosis prospective cohort.
In 624 patients with CVT, we compared the prognosis of patients submitted or not to LP. The primary outcome was 'death or dependency at 6 months', as evaluated by the modified Rankin Scale (mRS; mRS = 3-6, with adjustment for variables associated with poor prognosis); secondary outcomes were: 'worsening after admission'; 'acute death'; and 'complete recovery at 6 months' (mRS = 0-1). We analyzed the same outcomes in subgroups of patients with brain lesions on the admission computer tomography/magnetic resonance imaging.
LP was performed in 224 patients (35.9%). There was no difference in frequency of 'death or dependency at 6 months' between patients with or without LP [13.4% vs. 14.4%; odds ratio (OR) = 0.9, 95% confidence interval (CI) 0.6-1.5; P = 0.739]. LP was not associated with 'worsening after hospitalization' [21.5% vs. 23.5%; OR = 0.9, 95% CI 0.6-1.3; P = 0.577], 'acute death' [3.6% vs. 3.3%; OR = 1.1, 95% CI 0.5-2.7; P = 0.844] or 'complete recovery' [79.9% vs. 76.6%; OR = 1.2, 95% CI 0.8-1.7; P = 0.484]. In the subgroups of patients with brain lesions, the prognoses were not different between patients submitted or not to LP.
LP was not associated with the functional outcome of patients with CVT, suggesting that LP was not harmful in these patients. These results should not be generalized to patients with large brain lesions and risk of herniation where LP is contraindicated.
No preview · Article · Mar 2013 · European Journal of Neurology
[Show abstract][Hide abstract] ABSTRACT: Background:
Studies suggest that N-terminal-pro-brain natriuretic peptide (NT-proBNP) can be a biomarker of cardioembolic stroke. However, the best time to measure it after stroke is unknown. We studied the time course of NT-proBNP in patients with ischemic stroke.
Consecutive acute ischemic stroke patients were admitted over 10 months to a Stroke Unit. Stroke type was classified according to TOAST. Blood samples were drawn within 24, 48, and 72 hours after stroke. Friedman test was used to compare NT-proBNP values across the 3 times in all, cardioembolic and non-cardioembolic stroke patients. Post hoc analysis with Wilcoxon signed-rank tests was conducted with a Bonferroni correction. Mann-Whitney test was used to compare median values of NT-proBNP between cardioembolic and non-cardioembolic stroke patients. ROC curves were drawn to determine NT-proBNP accuracy to diagnose cardioembolic stroke at 24, 48, and 72 hours after stroke onset.
One hundred and one patients were included (29 cardioembolic) with a mean age of 64.5±12.3 years. NT-proBNP values for cardioembolic stroke were significantly higher (P < 0.001) than for non-cardioembolic stroke in the 3 time points. NT-proBNP was highest in the first 24-48 h after ischemic stroke and decreased significantly 72 h after stroke onset. The area under the curve for the three time points was similar.
NT-proBNP levels were highest in the first 2 days after ischemic stroke and declined significantly thereafter. However, the area under the curve for the three time points was similar. The first 72 hours after ischemic stroke have a similar diagnostic accuracy to diagnose cardioembolic stroke.
No preview · Article · Mar 2013 · Acta Neurologica Scandinavica
[Show abstract][Hide abstract] ABSTRACT: Epidemiology Thrombosis of the dural sinus and of the cerebral veins (CVT) is less common (0.5-1% of all strokes) than other types of stroke [1-3]. There are no population-based studies on the incidence of CVT. From hospital-based series incidence varies from 0.22/100000/year (IC 95% = 0-47) in Portugal  to 1.23/100000/year in Isfahan, Iran . The incidence is higher in pregnant and puerperal females (11.6/100000 deliveries in US) and in children (0.64/100000 in infants and children <18 years in Canada) . Among adults CVT predominates in females (3:1) and in younger adults, as less than 10% CVT patients are older than 65. Clinical features CVT can have an acute, subacute or less often chronic presentation. The most frequent symptoms are headaches, seizures, motor, sensory or language deficits, altered mental status, decreased consciousness, diplopia, and visual loss. Symptoms and signs can be grouped in three major presentation syndromes: isolated intracranial hypertension (headache, vomiting, papilloedema, and visual symptoms), focal syndrome (focal deficits, seizures or both), and encephalopathy (multifocal signs, mental status changes, stupor/coma) . Less common syndromes include thunderclap headache, mimicking subarachnoid hemorrhage, cavernous sinus syndrome (cavernous sinus thrombosis), pulsating tinnitus, and multiple lower cranial nerve palsies (lateral sinus thrombosis).
[Show abstract][Hide abstract] ABSTRACT: To examine the independent contributions and combined interactions of medial temporal lobe atrophy (MTA), cortical and subcortical atrophy, and white matter lesion (WML) volume in longitudinal cognitive performance.
A total of 477 subjects with age-related WML were evaluated with brain MRI and annual neuropsychological examinations in 3-year follow-up. Baseline MRI determinants of cognitive decline were analyzed with linear mixed models controlling for multiple confounders.
MTA and subcortical atrophy predicted significantly steeper rate of decline in global cognitive measures as well as compound scores for psychomotor speed, executive functions, and memory after adjusting for age, gender, education, lacunes/infarcts, and WML volume. Cortical atrophy independently predicted decline in psychomotor speed. WML volume remained significantly associated with cognitive decline even after controlling for the atrophy scores. Moreover, significant synergistic interactions were found between WML and atrophy measures in overall cognitive performance across time and the rate of cognitive decline. Synergistic effects were also observed between baseline lacunar infarcts and all atrophy measures on change in psychomotor speed. The main results remained robust after exclusion of subjects with clinical stroke or incident dementia, and after additional adjustments for progression of WML and lacunes.
Brain atrophy and WML are independently related to longitudinal cognitive decline in small vessel disease. MTA, subcortical, and cortical atrophy seem to potentiate the effect of WML and lacunes on cognitive decline.
[Show abstract][Hide abstract] ABSTRACT: Quantitative measurement of circulating D-dimer, a product of fibrin degradation, has been shown to be a very useful diagnostic tool in the management of patients with suspected deep vein thrombosis and/or pulmonary embolism. Whether D-dimer can play a similar role in the diagnostic approach to patients with suspected cerebral vein thrombosis (CVT) remains controversial.
Studies evaluating the diagnostic accuracy of the D-dimer test in the diagnosis of CVT were systematically searched for in the MEDLINE and EMBASE databases (up to July 2011). Weighted mean sensitivity and specificity with 95% confidence intervals (CIs) were calculated with a bivariate random-effects regression approach.
Fourteen studies, for a total of 1134 patients, were included. D-dimer accuracy was good, with a resulting weighted mean sensitivity of 93.9% (95% CI 87.5-97.1) and weighted mean specificity of 89.7% (95% CI 86.5-92.2), calculated with a bivariate approach. Potential risk factors for false-negative D-dimer results included isolated headache, longer duration of symptoms, and limited sinus involvement. ConclusIONS: Our findings suggest that D-dimer may be a useful diagnostic tool in the management of patients with suspected CVT. Future prospective studies are warranted to confirm our preliminary findings.
Preview · Article · Jan 2012 · Journal of Thrombosis and Haemostasis
[Show abstract][Hide abstract] ABSTRACT: Growth factors are thought to modulate neurological function in stroke recovery through effects in angiogenesis, neurogenesis, and neuroprotection.
We tested the association of variants in the brain-derived neurotrophic factor (BDNF), fibroblast growth factor 2 (FGF2) and vascular endothelial growth factor A (VEGFA) genes, and epistatic interactions between them, with functional outcome in a sample of 546 stroke patients.
While none of the tested genes was independently associated with stroke outcome, two significant gene-gene interaction models were identified. One model combined one BDNF and three FGF2 markers, with a global odds ratio (OR) (95% confidence interval [CI]) of 4.15 [2.86-6.04]. The second model included one FGF2 and two VEGFA markers with a global OR [95% CI] = 2.54 [1.76-3.67].
The results provide evidence for gene interactions in stroke outcome, highlighting the complexity of the recovery mechanisms after a stroke event.
Full-text · Article · Jan 2012 · European Journal of Neurology
[Show abstract][Hide abstract] ABSTRACT: Introduction Discussion of the role of subcortical structures in language and other higher nervous functions begins with the famous polemic opposing Déjerine (a corticalist) to Pierre Marie, who described several anatomoclinical cases of subcortical strokes causing aphasia and claimed that damage to an area including the insula and external capsule was crucial to the production of anarthria. However, during the next decades, few authors attributed any role to the thalamus or to other subcortical structures in relation to symbolic and cognitive behavior. With the widespread use of computerized tomography (CT), it has become evident that aphasia and other “cortical” syndromes can result from lesions limited to subcortical structures. Both single-photon emission computed tomography (SPECT) and positron emission tomography (PET) have shown that subcortical strokes are accompanied by important abnormalities of cortical metabolism and perfusion. Magnetic resonance imaging (MRI) can show cortical lesions that were not apparent on CT. These facts raise the question whether neurobehavioral disturbances seen after subcortical strokes are due to subcortical damage per se or are related to functional cortical inactivation (diaschisis), cortical hypoperfusion, or subtle concomitant cortical lesions. Strokes in the basal ganglia and deep white matter tracts can produce disorders of oral and written language, apraxia, neglect, amnesia, apathy, and several other psychiatric disturbances. Multiple subcortical lacunar stroke and vascular white matter changes are associated with cognitive impairment, cognitive decline, depression, and dementia .
[Show abstract][Hide abstract] ABSTRACT: The first two editions of Stroke Syndromes were widely welcomed as authoritative reference works in the assessment and diagnosis of stroke. This revised and updated third edition remains the definitive guide to patterns and syndromes in stroke. A comprehensive survey of all types of neurological, neurophysiological and other clinical dysfunction due to stroke. The book contains descriptions of clinical problems encountered in stroke patients and their differential diagnosis, enhancing pattern recognition and enabling clinicians to differentiate between possible locations on the basis of symptoms and signs. The companion volume Uncommon Causes of Stroke completes this highly authoritative reference work which clinicians in neurology will find essential to the understanding and diagnosis of stroke.
[Show abstract][Hide abstract] ABSTRACT: Apathy is a frequent disturbance in stroke patients. The aim of this case-control study was to elucidate whether apathy: (i) was secondary to stroke or related to hospitalization, (ii) was related to thalamic and striatocapsular stroke lesions, (iii) was independent from cognitive impairment and depression in the acute phase of stroke, (iv) was associated with clinical and demographical variables and (v) was associated with a worse functional outcome at discharge.
We assessed a sample of 94 consecutive patients with an acute (≤4 days) stroke (22 intracerebral haemorrhages, 72 cerebral infarcts), and a control group of 50 patients with acute coronary syndrome, with the 10-item Apathy Evaluation Scale-Clinical. We related apathy with cognition (MMSE), depression (Montgomery Åsberg Depression Rating Scale) and with outcome (modified Rankin Scale).
Apathy was present in 36 (38.3%) acute stroke patients but was also frequent in patients with acute coronary syndrome (24%). Stroke patients were more inaccurate in understanding their problems than patients with acute coronary syndrome (P=0.005). Logistic regression identified cerebral haemorrhage (OR=3.5), low educational level (OR=4.7) and a trend of right hemispherical lesion (OR=3.0) as independent predictors for apathy (R(2)=32.3%). Cognitive impairment and depression were not associated to apathy. Apathy was associated with a worse outcome (P=0.03).
Apathy was frequent in acute stroke patients, and it was predicted by acute intracerebral haemorrhage and right hemispherical acute stroke lesion.
Full-text · Article · Sep 2011 · European Journal of Neurology
[Show abstract][Hide abstract] ABSTRACT: In cerebral small vessel disease, the core MRI findings include white matter lesions (WML) and lacunar infarcts. While the clinical significance of WML is better understood, the contribution of lacunes to the rate of cognitive decline has not been established. This study investigated whether incident lacunes on MRI determine longitudinal cognitive change in elderly subjects with WML.
Within the Leukoaraiosis and Disability Study (LADIS), 387 subjects were evaluated with repeated MRI and neuropsychological assessment at baseline and after 3 years. Predictors of change in global cognitive function and specific cognitive domains over time were analyzed with multivariate linear regression.
After controlling for demographic factors, baseline cognitive performance, baseline lacunar and WML lesion load, and WML progression, the number of new lacunes was related to subtle decrease in compound scores for executive functions (p = 0.021) and speed and motor control (p = 0.045), but not for memory or global cognitive function. Irrespective of lacunes, WML progression was associated with decrease in executive functions score (p = 0.016).
Incident lacunes on MRI parallel a steeper rate of decline in executive functions and psychomotor speed. Accordingly, in addition to WML, lacunes determine longitudinal cognitive impairment in small vessel disease. Although the individual contribution of lacunes on cognition was modest, they cannot be considered benign findings, but indicate a risk of progressive cognitive impairment.
[Show abstract][Hide abstract] ABSTRACT: The aim of this 3-year follow-up study was to investigate whether corpus callosum (CC) atrophy may predict future motor and cognitive impairment in an elderly population. On baseline MRI from 563 subjects with age-related white matter changes (ARWMC) from the Leukoaraiosis And DISability (LADIS) study, the CC was segmented and subdivided into five anterior-posterior regions (CC1-CC5). Associations between the CC areas and decline in motor performance and cognitive functions over a 3-year period were analyzed. CC atrophy at baseline was significantly associated with impaired cognitive performance (p<0.01 for CC1, p<0.05 for CC5), motor function (p<0.05 for CC2 and CC5), and walking speed (p<0.01 for CC2 and CC5, p<0.05 for CC3 and total CC), and with development of dementia at 3 years (p<0.05 for CC1) after correction for appropriate confounders (ARWMC volume, atrophy, age, gender and handedness). In conclusion, CC atrophy, an indicator of reduced functional connectivity between cortical areas, seems to contribute, independently of ARWMC load, to future cognitive and motor decline in the elderly.
No preview · Article · May 2011 · Journal of the neurological sciences